Inspection on 27/10/08 for Astley House Care Centre

This inspection was carried out on 27th October 2008.

CSCI found this care home to be providing an Poor service.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Astley House Care Centre 08/05/09

Astley House Care Centre 22/05/08

Astley House Care Centre 03/12/07

Astley House Care Centre 12/06/07

Astley House Care Centre 06/06/06

Astley House Care Centre 28/06/05

Astley House Care Centre 18/01/05

Astley House Care Centre 24/08/04

Astley House Care Centre 24/02/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 06/02/2009.

CARE HOMES FOR OLDER PEOPLE Astley House Care Centre 1 Lypiatt Road Cheltenham Glos GL50 2SY Lead Inspector Mrs Janice Patrick Unannounced Inspection 10:00 27th October & 10 & 12 November 2008 th th X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Astley House Care Centre Address 1 Lypiatt Road Cheltenham Glos GL50 2SY Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 08453 455742 01242 255971 helen.haughton@blanchworth.co.uk Mrs Sally Anne Manby Roberts Mr Jeremy Walsh, Mr Roy Harris Manager post vacant Care Home 33 Category(ies) of Dementia - over 65 years of age (6), Old age, registration, with number not falling within any other category (27) of places Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 7th proposed Dementia Care bed, currently occupied by one named service user without a diagnosis of Dementia, will become a 7th Dementia Care bed when that specified service user no longer requires the bed on their discharge or death. 22nd May 2008 Date of last inspection Brief Description of the Service: This care home is situated in a residential area very near to Cheltenham Town centre and is in close proximity to local shops, amenities and bus services. It provides nursing and personal care, predominantly to the older person. There are six beds designated to the care of those with dementia. These are not separate but integrated within the home. All bedrooms have en suite facilities; there are ample communal rooms and additional bathrooms and toilets. There is a passenger lift large enough to accommodate a wheelchair dependant person and one escort. Behind the home is a sizeable paved garden area, which provides safe outdoor space, accessible by wheelchair. Off road parking is provided at the front of the building for a number of cars. There are steps to the front entrance but wheelchair access can be gained through a side gate which leads to the paved area and its entrance. The fees depend on the type of care being provided and the room occupied. Fees at the time of this inspection range from £475.00 (personal care, single room with en suite) to £654.00 (higher nursing care, single room with bath en suite). The home’s terms and conditions outline any additional charges. Information about the home can be found in the reception area. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 0 star. This means the people who use this service experience poor quality outcomes. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. It also takes into consideration the views and reports from visiting healthcare professionals. We (The Commission for Social Care Inspection, CSCI) carried out this inspection over three days. This was a Key Inspection and the pharmacist inspector reviewed some of the arrangements for the management of medication. This was to see if the improvement found at the last inspection of medication had been sustained and what further actions have been taken to improve and deal with remaining concerns we raised. The way medicines were given to some people in the home was observed and we also spoke to one resident and one relative in respect of this. We spoke with the registered nurse in charge, a manager from another Blanchworth home (the acting manager) who was helping out and a representative from Blanchworth Head Office (the senior company manager) who has some oversight of this home. The pharmacy inspection took place over six hours on the first day (27/10/08). We also inspected the care that people were receiving and the records maintained in relation to this. We looked at what involvement external healthcare professionals have in meeting peoples’ health care needs. We explored how peoples’ privacy and dignity is maintained and how they are assisted to make choices and have a say in what happens to them. We inspected areas that give added quality to someone’s life, such as opportunities to socialise, recreational activities, the choice and standard of food and how clean the home is. We inspected the arrangements in place to safeguard vulnerable adults. We explored the processes in place for people to make a complaint or express a concern and if these are taken seriously and acted upon. We inspected the records held in relation to staff recruitment, staff training and supervision. We looked at the duty rosters to see if the home has enough staff in number and competency on duty, to meet the needs of the people living there. We inspected the management arrangements. We reviewed the systems that help monitor and highlight practices within the home and how any shortfalls are identified and improved upon. We explored the ways that staff communicate with those living in the home and with those that visit and how peoples’ views about the service are sought. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 6 We inspected a selection of records in relation to health and safety and looked for evidence of safe practice. We revisited the outstanding requirements made by us in a previous inspection to see if these had been complied with. What the service does well: What has improved since the last inspection? What they could do better: The written care plans for those who receive nursing care still require a total review to make them relevant to the person’s current needs. The care plans and associated assessments need to be written and managed competently so that they offer staff the guidance they require to be able to provide appropriate and safe care. Staff need then, to be aware of the guidance and adhere to it. Plans of care and any associated records relating to wound care and pressure care need to be competently maintained so that all staff reading them can understand what care is required and when and what care was last given. Provide staff with more training in the areas that require improvement and broaden skills by ensuring that external agencies or healthcare professionals provide that training as a compliment to any training arranged ‘in house’. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 7 There are still some areas of weakness in the arrangements for the management of medicines where more attention is needed in order to help protect people living in the home from unnecessary risks with medication. A better balance of staff skill is required on each shift so that those who are not so skilled and knowledgeable can receive adequate supervision and support from those that are. Although the choice of food has improved, the standard of what is being provided appears variable and needs to be appetising and nourishing at every meal. The home is still requires effective and consistent management and a period of sustained improvement throughout is necessary. Compliance with the Care Home Regulations 2001 is repeatedly failing and this must be rectified so that people in the home are not placed at risk. Although the choice of food has improved, the standard of what is being provided appears variable and needs to be appetising and nourishing at every meal. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 & 6 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. This home is not in a position to be able to fully demonstrate and reassure people that their needs would be fully met if they moved in. EVIDENCE: The local funding authority is not currently ‘placing’ people in this home. This decision was made as part of a safeguarding adults process. As part of this process all residents in the home have had their needs reassessed by the Community Adult Care Directorate (CACD, formally Social Services and the Primary Healthcare Trust PCT). It should be noted that at this point that the Registered Provider also, voluntarily agreed not to admit anyone who funds his or her own care. There have been no admissions to the home as a result of the above decision. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 10 Repeated non-compliance with the Care Home Regulations 2001 in respect of specific health care outcomes for residents (full report in Health and Personal Care outcome) still leaves us with serious concerns. More worryingly is the fact that these shortfalls are still evident following a period of time where support has been given to the service by external healthcare professionals i.e. the Community Adult Care Directorate and the Primary Healthcare Trust. The services will react to shortfalls pointed out to them but appear unable to identify these independently and sustain improvement. The competency of some staff remains very questionable in respect of many of these shortfalls. The Care Home Support Team has been visiting the service. A member of this team visited during our inspection and planned to provide the qualified nurses with support and training in recognising their responsibilities and legal accountability. This should not really be necessary as each individual nurse practicing in the United Kingdom should be aware of and capable of adhering to the CODE of Practice and Conduct expected by the Nursing and Midwifery Council (NMC). During this inspection we made sure that the current acting manager had a contact number for the Skills for Care co-ordinator, so that any additional, free training for care staff could be accessed. We were told that the company has already organised future wound care training. The service therefore remains fragile and we have not completed this inspection with the required reassurances to enable us to believe that peoples’ needs are fully met. The close monitoring of the service by external healthcare professionals and us will therefore continue and the Commission will decide on what further action will be appropriate to secure compliance. This home does not provide intermediate care. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Some staff are genuinely committed to doing their best when it comes to looking after the residents, but a lack of strong leadership and basic skills are repeatedly letting residents down and placing them at risk and this cannot be left to continue. EVIDENCE: Shortfalls in the planning and delivery of care have been occurring since early 2007. Particular requirements relating to wound care, pressure area care and care planning were still not complied with in June of this year, so in July we initiated the next step of our enforcement pathway and issued a Statutory Requirement Notice to try and secure compliance. Since 2007 the standard of record keeping and care planning has been poor and it remains so as demonstrated in this report. The Statutory Requirement Notice in this respect has not been complied with. As part of the safeguarding adults process, we have been liaising with external healthcare professionals who continue to visit the home. They have reported Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 12 that their recommendations have been implemented and the condition of some of the more complex wounds has improved with specialist intervention and guidance. We saw that the records for two of these wounds were being maintained. However, despite this positive news, when we looked at the wound care and pressure care records of six other residents we saw repeated failings. These related to the recording of wounds when they occur, the treatment provided and its care planning, the planning of future reviews, demonstrating that those reviews took place and general ongoing monitoring of fragile skin that is at risk of deteriorating and becoming a pressure sore. These shortfalls are best described in the findings listed below: 1. First resident: wound care records tell us that a wound on this person’s arm was redressed on 24/10/08 and that it should be reviewed on the 26/10/08. There was no further written entry in relation to this, therefore we were unable to substantiate that any review of this wound had taken place. The review date had not been transferred to the diary or the care board to remind staff. The transferring of review dates to the diary had been agreed during our last inspection for this very reason, so that wounds would not get forgotten. We asked a nurse in the home, who had been on duty several days since the 24th if she knew what condition the wound was in. This nurse ‘thought’ she may have viewed it since the 24th but she was not sure. We asked her that if she had viewed it would she have recorded this as is required but she was unable to give an answer. Due to this uncertainty we asked to see the wound with the acting manager who suggested she look at it immediately. We found a bandage wrapped around the arm, under clothing, which had become quite tight around the upper arm, acting as a mild tourniquet. The skin beneath had healed but was generally extremely dry and flaky and required attention. We asked one carer why she thought the bandage was in place. She thought it was there to protect the person’s frail skin, which we understand had been the practice, but she was unaware of the recent injury. 2. Second resident: an entry in one part of the wound care records indicated that a dry ‘skin flap’ type of wound had been found on the resident’s leg on 5/11/08. Records said that this had been covered with a ‘dry dressing’. In another part of the record there was a different entry describing the use of a different type of dressing on the same day. Records showed that this wound had been reviewed on the 8/11/08 and was due to be reviewed on the 12/11/08, the day of this inspection. This review had not taken place by 6pm so we asked the resident and the acting manager if we could see it. When the top dressing was removed a second different type of dressing was seen underneath, the use of this dressing material had not been recorded but the wound was clean but now wet with an obvious area of skin that needed to heal. Our concerns again, were that the review date of the 12th had not been transferred to the diary and there appeared to have been no plan to review this wound today, in fact the nurse on duty was unaware of the dressing being in Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 13 3. 4. 5. 6. place. There was no accident report recorded telling us how this occurred. We looked at the nurse handover forms for the date that the first dressing was applied to see if anything had been discussed, it had not. This was particularly worrying as this person had been part of our safeguarding referral as we concerned at the time about the number of injuries she was getting to the same leg, but with what appeared to be no evidence of anything being done to prevent this. External healthcare professionals subsequently investigated this and it was thought to be due to be due to the way the resident was being transferred from chair to wheelchair or vice versa. Third resident: care records indicated that an external healthcare professional had attended to a wound on 30/10/08. The date for review was recorded as 01/11/08 on the wound care record. This date had not been transferred to the diary and there was no further record implying that this wound had been reviewed. In fact, there was an unexplained gap of 11 days, up until the day we were looking at this (10/11/08). This wound was subsequently redressed on 10/11/08 and again on 12/11/08. Two further dressings were found on this resident, of which there were no relevant records. Staff later informed us that one of the injuries (a graze), had been attended to on the 11/11/08, and had possibly been caused by the metal zip of a protective pad that staff were using to relieve pressure between the knees. The records for a further wound were being maintained. Fourth resident: entries in the care records described a history of the skin on this resident’s buttock being fragile and susceptible to developing a pressure sore. They recorded cycles of the skin being red, breaking and then healing again. On the 29/10/08 an entry said ‘bottom broken again, dressing applied’. This was the last entry seen recorded in relation to any treatment or monitoring. The acting manager, new to the home, was not sure of the skins current condition when we asked. She therefore examined this and found the skin to be fragile and very red. If not monitored carefully this would repeat its cycle and ‘ breakdown’ again, putting the resident at risk of developing an open pressure sore. Remedial action was taken at the time of this inspection and a written plan of care was subsequently forwarded to us, as requested. Fifth resident: the records told us that this resident had had a dressing applied on the 29/10/08. When the agency nurse on duty reviewed this area of the resident’s skin on the 12/11/08, there was no dressing in place but the skin was broken. Again, this could potentially have developed into a more serious pressure sore. There was no monitoring or care recorded since the 29/10/08. On investigation there was no more stock of the previously used dressing so, the agency nurse, with permission from the acting manager, used an alternative product to protect the area from infection. Sixth resident: this person is having regular treatment and support from an external healthcare specialist in relation to a deep pressure sore. This resident is extremely frail and her ability to heal is already severely DS0000016373.V372942.R01.S.doc Version 5.2 Page 14 Astley House Care Centre compromised. It is therefore imperative that the correct pressure relief care is provided. A specialist mattress is on loan from the local health authority and the written care plan says that her weight must be alternated (by physically changing her position) every two hours (three at night) to relieve the pressure on the skin, in other areas of the body. On the 12/11/08 this resident’s position was not altered between 6am and 12 midday. This is a serious omission of care and we therefore reported this incident to the local Safeguarding Adults Team. An urgent review of this resident’s care was subsequently organised by the local funding authority in line with safeguarding adult processes following our inspection. The wound care records showed evidence of external support being given to the home by a specialist wound care health professional and records of when wound care was taking place were being correctly maintained. However, the actual directions within the wound care plan were unclear. We had to search through the nurses recorded entries to find an explanation for the two sets of directions recorded on the care plan (the document that should give up to date relevant instruction). There had been a change in treatment but the care plan still showed the old treatment plan as well as the new one. The agency nurse confirmed that she had been told in the morning ‘handover’ on the 12/11/08 that the wound care specialist would come and attend to the wound at some point during the day. By early evening this had not happened and no one present in the home had been shown how to carry out the treatment. We therefore requested that arrangements be made for this resident to receive the required treatment, as due on the 12/11/08. The acting manager organised for the two nurses who have been shown the procedure to come to the home on the way back from their study day and attend to the wound. All of the above were discussed with the new acting manager and Director of Care as and when they were identified on the 12/11/08. Evidence relating to the above shortfalls was taken under Code B of the Police and Criminal Evidence Act (PACE) and a decision will be made by the Commission as to what further action is required to protect the residents in the home. We also raised other concerns that fall within this outcome: 1. The resident that had not been turned between 6am and 12 midday had also, by 11 am only received 30mls of fluid since 8am. There was no record of any breakfast being given prior to 11am. After speaking with care staff this was found to be correct. We informed staff that this was totally unacceptable for anyone but in this resident’s case it is even more imperative that she receive regular and ample fluids because of the ‘negative pressure’ treatment being used on the wound. This is designed to remove the excess fluid waste from a deep wound site in order to protect delicate, surrounding tissue. This is therefore an additional site for losing body fluid. This resident also has a urinary catheter in place, Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 15 requiring the kidneys and bladder to be adequately flushed with fluid. She also requires regular, nutritional support as her body tries to heal an open wound. We spoke to the permanent member of staff responsible for providing this person’s care on 12/11/08 and took an account of why this care had been missed. 2. We also found another resident to be having a full bed bath, change of bedclothes and bed linen at 2.45pm. The same carer initially told us that this was being done because the resident had been incontinent and was perspiring. Attention to this resident’s personal care needs would be expected in this situation, however, the member of staff went on to explain that they had only had time in the morning to carry out a ‘quick wash’. This carer explained that they had been allocated the care of six residents in the morning and this is why the resident above only had a quick wash in the morning. Senior management staff explained that they had told this carer to come and get their help if it was needed. We asked the carer how they had managed to change this resident’s continence pad on their own. We were told that this had been possible because the resident had been lying on their side and the continence pad could be pulled through the legs. This action would have caused potential scuffing of the skin and because of the resident’s position it would have been impossible to have properly cleansed the areas between the legs. This resident is incontinent both of urine and faeces. We were also informed that an attempt to alter the resident’s position had failed because she had just rolled back on to her original side. This resident’s moving and handling care assessment, last updated in July of this year, clearly states that two staff must carry out any care that involves manoeuvring the resident and that a hoist or slide sheet should be used to assist this process. The above examples have a direct impact on residents’ health and wellbeing. A requirement first made by us in May 2007 was for all care plans to be relevant to the current needs of the residents, for them to be appropriately updated and to be written competently. This is necessary so that all staff know how someone’s needs are to be met and how to do it safely. The care plan may also contain the specific wishes of the resident or their representative so they are an integral part of care delivery. It is a legal requirement for accurate records to be kept of care provided, particularly any nursing care. On the 10/11/08 we were informed that all care plans relating to residents who only required personal care had been updated and transferred over to the new format (improved documentation introduced by the company to make the records more ‘user friendly’ and to meet some of the new criteria, such as that within the Mental Capacity Act 2005). This was not apparently the case for those receiving nursing care. Various reasons for this shortfall have been given to us by the Registered Provider and include: acting managers leaving for various reasons, not being able to recruit an acting manager because of a possible sale of the home and most recently Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 16 the last acting manager’s refusal to write care plans. All of these situations we acknowledge as being a problem; they do not however, explain why the registered nurses in the home have not been maintaining these records correctly as part of their professional accountability. We inspected the nutritional records of two residents. One had put on weight since our last inspection and another had lost some weight and had been commenced on a food intake chart to help monitor this. Another resident had gained seven kilograms since our last inspection. This resident had virtually stopped eating anything but the senior company manager explained that by encouraging her to sit with other residents at mealtimes, this seems to have improved her mood generally. Records now show that this resident, along with others is being provided (asked if they would like) a cooked breakfast rather than the menu just saying that ‘a cooked breakfast is available on request’. Another resident’s care plan said she was to have a thickener in her drinks. This was an example of a care plan not being clear as it said ‘if required’. There was some debate as to whether her tea contained this but her squash certainly did not. We were also concerned as to how staff were monitoring this resident’s Body Mass Index (BMI). It was explained that because this resident was confined to bed she could not be weighed in the conventional way but that her BMI was being recorded. However, records show that measurements had been taken from the left and the right arm, meaning that the results are likely to be flawed. A measurement needs to be taken from the same site each time to give an accurate record. We found that not all residents’ monthly weights were recorded in their care records. We asked if these had been recorded anywhere else, which resulted in an incomplete list being found for October. We observed staff being polite and respectful towards the residents. Several residents commented that the staff were helpful and kind. Residents’ privacy appeared to be being respected and by providing a designated place for residents to be able to take their visitors will improve this further. Pharmacist’s Report Registered nurses were responsible for the management of medication on behalf of people living in the home. The nurses have recently received additional training and assessment in the safe handling of medicines and one more nurse was booked for this training soon. We were told syringe driver training for the nurses was booked and would be in place by December 2008. We agreed to extend the date for this requirement as there has been some difficulty in finding suitable training. This treatment was not in use at the time of the inspection, nor had it been since we first identified this as a weakness in June 2008. At the time of the inspection nobody was assessed as able to self-administer any of their medicines. We saw the nurse administering some medicines safely Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 17 at lunchtime. People living in the home had finished their lunch so this did not interfere with their meal. Consideration must still be given as to how to administer medicines should there be a direction to take before food. When we first arrived 10.30am the nurse had finished administering the morning doses of medicines so this was completed by a better time than at previous inspections. We again saw that the nurse did not always make an immediate record of medicines administered. After we arrived the medicine charts for a number of people were signed together. This is considered poor practice that can lead to errors and omissions in recording (see below) and so put people at risk. We have raised this issue at previous inspections of medication. For each person living in the home there were arrangements for recording medication received, administered and leaving the home or disposed of (as no longer needed). Complete and accurate records about medication are important so that there is a full account of the medicines the home is responsible for on behalf of the people living here and so that people are not at risk from mistakes, such as receiving their medicines incorrectly. We looked at a sample of these records in more detail and these generally appeared to be in order. We identified some weaknesses where more attention to detail was needed. We found occasional gaps in the records; some of these the nurse on duty explained about as they were for the morning of the inspection. The nurse said she had missed recording correctly. For others we could find not explanation. This was could be because records were not always checked and signed immediately the medicine was taken or refused. Records for creams or ointments applied to the skin were not always made and on some medicine charts it was hard to tell if the creams were still supposed to be used or the treatment had been missed. On some interim charts for medicines supplied between the normal monthly orders the dates on the chart were not completely noted or a start date was not included so it was hard to see what period the medicines were given. We questioned why one treatment prescribed to use four times daily was generally only signed three times daily. The nurse explained the reasons and during the inspection the doctor who visited clarified the directions. We spoke to this person and his or her relative about their care; they were satisfied and confirmed nurses gave his or her medicines. Confirmation of warfarin dose for one person recently was not in writing as directed in the Anticoagulant patient safety alert from the NHS National Patient Safety Agency and as had been the case at the last medication inspection. Staff said they had recently experienced problems getting these from the surgery. We have raised this with the local PCT and one of the Blanchworth managers has followed this up with the surgery. For one person there had been some confusion between the surgery and pharmacy over the dose of a particular medicine prescribed as 50mg and 150mg capsules and tablets. Staff in the home had documented actions taken to sort out the proper dose. More careful recording about the various dose changes in the care plan could have helped resolve this more quickly. Staff Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 18 said they do see doctors’ prescriptions before they are sent to the pharmacy. This should have identified that the prescription for one strength was not provided. Each person had a medication administration choice and capacity form, which is a good practice and provided useful additional information about each person’s choices. We did see occasional examples where the information about medicines used as required needed reviewing as this had changed since the forms were completed. For example for one person the form indicated there were no medicines used ‘as required’ yet we saw two with this direction on the current medication record and these were mentioned in the care plan. A number of medicines were prescribed to use ‘as required’. In the records we looked at we found for some people there were entries in various care plans where there was information about the relevant medicines that provided further guidance to the staff responsible for administering medication. In other plans more detail was needed to give clear guidance and for other medicines there was no such guidance. This information is necessary to help make sure people receive their medicines in a consistent way and to meet identified needs. We pointed out in one care plan we looked at where the medicine in question was mentioned but more information was needed to give better guidance about using an extra dose. In another plan more information about a ‘normal’ bowel habit for this person was needed in relation to use of a laxative. For another person the sleeping care plan included the medicine but gave no specific guidance about how staff make a decision to use. This person was also prescribed a regular and ‘as required’ analgesic but we could find nothing in the care plan about the ‘as required’ doses. The records did not say if one or two of these tablets had been administered. This person was also prescribed a twice-weekly catheter maintenance solution but no doses were signed as used from 13th to 27th October 2008 and some entries on the medicine chart indicated this was out of stock. We in fact found a full box of this solution in the medicine cupboard (dispensed on 2nd October 2008). It seemed this might have been muddled by staff with stock of the same solution labelled for another person. There was a care plan for the catheter but no specific information about using this solution twice weekly. We saw for one person there were no senna tablets in stock and the records did not account for the 28 tablets dispensed on 17.09.08 and signed as received. The manager must look into the reason for this. Staff had already followed up obtaining a new prescription but said this person did not need this at the moment as another laxative was also in use. The care plan needed to be revised to reflect this. We also saw good practice in one care plan where dietary and other implications of a treatment with a particular medicine were explained. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 19 Medicines were stored safely at the correct temperature and the medicine room was much tidier than at the last inspection with additional stock control procedures in place. There were proper storage arrangements for controlled medication. Checks we made with the controlled medicine record book were in order. There was however no evidence of regular weekly checks of these medicines as stated in the Blanchworth medication policy. The latest version of the company medication policy and procedures was available in the clinic room so that all staff should be aware of how the company expected medication to be handled in a safe way. We noted the homely remedies protocols were not dated so we did not know when these were last reviewed. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 20 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Efforts have been made to improve residents’ social activities and their ability to choose what they would like to eat. However, the food provided needs to be of a more consistent standard and the support to those that are dependant on help to eat and drink must improve. EVIDENCE: When we arrived in the home on 10/11/08 at 10.20am the atmosphere was calm and our initial impression was that it looked cleaner and more organised. A member of the domestic staff let us in, but on walking through the communal rooms we could not see any care staff. We saw six residents asleep in the dining room area, either seated in their wheelchairs or sitting in a dining room chair with crockery in front of them. One was having a cup of tea. Four others were in the lounge areas, some were awake, and others were asleep. After ten minutes we went down to the lower ground floor to look for staff. The activities co-ordinator was coming out of the bedroom of a resident who is confined to bed. On returning to the ground floor, we were met by other staff. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 21 The cook told us that a carer is now responsible for the dining room at breakfast time and that this enables her to concentrate on what she has to do in the kitchen. After finding residents still in the dining room at 10.20am, asleep, we wondered if, after some initial help at breakfast, residents then have to wait to get back to a comfortable armchair. We asked a carer how many other residents there were to get up or bring down. We were informed that anyone left in their bedrooms were either confined to their beds or did not wish to come down and that all had been attended to and had their breakfast. In previous inspections the activities co-ordinator has been included in the numbers of care staff delivering basic care between 7am and 10am (see ‘Staffing’ outcome in this report). It has been difficult for her sometimes to break off from her role as carer in order to start the activities at 10am, because there have still been residents requiring help to get up at 10am. Basic care requirements have therefore had to take priority over residents’ social needs. Relatives and residents have previously commented that activities have either started late, as we have witnessed in the past, or have been postponed. An alteration in the activity co-ordinators hours of work has obviously been done to try and improve this situation. We spoke to two staff who agreed that having an extra fifth carer on duty, as well as the activities coordinator at 10am, has made it less stressful and rushed. This we feel must be of benefit to the residents. However, on the 12/11/08 there were only four care staff and the activities coordinator and as evidenced this number and the skill mix on this day (see Staffing outcome) had a serious impact on the residents. During this inspection we saw the activities co-ordinator escort two residents on a walk outside and other residents participating in games, quizzes and discussions. In July of this year we also issued a Statutory Requirement Notice relating to residents’ being able to have their choices and preferences recognised and acted upon. This referred to the home’s general routine at the time not allowing for this but particularly related to a lack of choice in food. As reported above, one member of staff is now allocated to the dining room at breakfast time so that residents are supported to make their choices and receive dedicated help to eat. Records held in the kitchen confirm that two options are now being provided each day, including further alternatives if needed. The senior company manager said that several residents are now enjoying cooked options for breakfast. We saw a blackboard in the dining room reminding residents of the daily choice at lunch time and teatime. In monthly reports to the Commission (regulation 26 visits), senior managers have confirmed that they are observing staff asking residents what they would Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 22 like to eat. Residents also told us that they are offered alternatives if they did not like either dish of the day. On the 10/11/08 we asked the cook what was for lunch. We were told, sausages or sliced chicken and that several alternatives could be provided if needed. On observing lunch we saw what appeared to be wafer thin slices of meat in gravy. We were concerned that this was the type of sliced chicken used for sandwiches and asked senior managers to investigate. This was confirmed as being so, to the shock of the senior manager on duty that day. It has subsequently been confirmed by the Director of Care that this was not heated up and will not be served in this manner again. The other main choice on this day was sausages. Clearly some people had problems eating these as chewed remains were on several plates. Some residents had gravy but others did not and the mashed potato and mixed vegetables that accompanied it looked unappetising. We commented on a lack of sauces such as brown and red sauce. The senior manager said this had already been considered and sauces were on order. Each table received the vegetables in serving dishes and salt and pepper, along with a drink were available. We noticed that some residents had enjoyed a sherry before lunch. On this same day we found one resident on the edge of her bed trying to eat her lunch. After encouraging the resident to manoeuvre herself more fully on to the mattress we reported this to the acting manager. We asked her to follow up why someone had left this resident’s lunch tray sideways on her bed table, on a slope and then left the table sideways on to the bed; all at a distance that the resident would find difficult to reach. On the 12/11/08 the acting manager told us that no one had admitted to doing this and that normally this resident is helped to sit in her bedroom armchair. On the 12/11/08 the agency nurse said that lunch appeared to go well and that she had had some of the Shepherds Pie and said how tasty it had been. We saw the conservatory on the ground floor being decorated. This room has been used as a storage area for sometime. The senior company manager explained that it is to be fitted out with new armchairs and made available for residents and their visitors to use. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 23 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There has been an improvement in the way complaints and concerns have been acknowledged and acted upon which has left those that have raised these feeling reassured. Residents will benefit from the current leadership, which is fostering a better understanding of abuse and safeguarding issues as well as identifying poor practices. However, this approach needs to be consistent and sustained in order for us, visiting healthcare professionals and relatives to be reassured that the risks to residents can be reduced and ultimately eradicated. EVIDENCE: We looked at the home’s complaint file. This contained a complaint made to the Registered Provider in September of this year, which had been responded to by the company’s senior manager, currently supporting the home. This was from a relative who had raised concerns about how often her relative was being bathed, problems with the provision of continence pads, the lack of staffs’ knowledge about her relative’s specific condition and concerns relating to the provision of this resident’s food. This relative also felt that residents generally should have access to fresh fruit. This complaint was formally acknowledged, investigated and action taken within the set timescales described by the home in their complaints procedure/policy. A record of the action taken was also recorded and more detail given to us at the time of this Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 24 inspection, regarding a planned continence assessment and training that staff have received from a specialist practitioner from Bristol. We also saw bowls of fresh fruit and snacks, which residents were either being offered or were helping themselves to. We spoke to this relative who confirmed that she felt reassured that her points of complaint had been taken seriously and acted upon. She also felt that the overall cleanliness of the home had improved but remained concerned that the home lacks consistent management. We are also aware of concerns being raised by another relative prior to this inspection, which we spoke to the senior manager about, as we knew these had been raised with her. These were not recorded in the complaints file; the reason given for this was that they were not received as a formal complaint. We would suggest that any concern raised is recorded with the action taken. Certainly these concerns are not new to the company and have also been raised with the funding authority in the past and again more recently because the relative felt that they were not being taken seriously. The senior manager confirmed that she had begun to act on some of the issues raised. One of the issues raised by the relative was a lack of personal care being given to her relative. We spoke to a carer who knew the resident in question well. She explained that the resident would often refuse help to wash, bathe or wash her hair. The carer said that this refusal has to be respected. The senior company manager explained that this has been explained to the relative. She said that they now try to ensure that this resident is offered personal care from someone they know she likes and that if she refuses it is offered again later. All offers and refusals are now being recorded. The General Practitioner has also been made aware of the situation in case there is a possible underlying medical reason why the resident is refusing. We have spoken with this relative, as have other healthcare professionals and she too, feels reassured that the senior company manager has listened to her concerns and acted upon them. This relative also commented positively about the replacement of some of the older, offensive smelling armchairs. Staff who work for the company automatically receive awareness training on the Protection of Vulnerable Adults (POVA). The company also have policies and procedures relating to adult protection and POVA in place. Some of the shortfalls taking place in the practices within this home demonstrate that staff require far more training and support to identify and realise what poor care delivery is and its connection with abuse. The subject of safeguarding adults has been raised in other trainings such as wound care and safe moving and handling so far. We have witnessed the current senior managers act in a way that is committed to stamping out poor practices and which demonstrate a zero tolerance of any form of abuse, once it has been brought to their attention. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 25 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 24, 25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents will benefit from living in a home that is currently being cleaned properly and where arrangements have been made to improve levels of infection control. EVIDENCE: It was obvious to us that some improvements have now been made to the cleanliness of the environment. One bedroom in particular has a new, washable, ‘non slip’ type of covering, which has got rid of the odour. We also noted that a lounge area off this bedroom had been redecorated, that the curtains were hanging on their hooks properly and that there were two new armchairs in place. This gives the feeling that the area is being cared for and maintained. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 26 We saw another bedroom, which looked vastly improved since a new carpet has been fitted. Another bedroom visited with the acting manager was odorous and she was going to get this sorted out. A crack in the wall by the en suite is still evident. A damp issue has now been dealt with in another bedroom but it took visiting healthcare professionals to reiterate the problem to get this done. We noted that the home has taken the advice, also given by external healthcare professionals, to make sure that all bathroom and toilet areas have soap and towel dispensers so that effective hand washing can take place. The senior company manager confirmed that they now have three cleaning staff, working fulltime over seven days a week. She has reviewed their working routine, along with that of the laundry and the alterations appear to be making a difference. Other armchairs in communal areas have been thrown out and replacements have arrived. We saw care staff wearing protective aprons when serving food and when providing certain levels of personal care. There were also supplies of plastic gloves and alcohol gels for hand cleanliness around the home. The acting manager confirmed that they were waiting for a new base to one of the hoists as this had begun to peel and could not be cleaned properly. We also witnessed the arrival of a new electronic hoist. At the time of this inspection the kitchen looked tidy each time we visited it. We did not inspect any specific cleaning schedules for this area. The home was warm and appeared to be adequately lit. Individual bedrooms varied, some had been personalised and made to look very ‘homely’ others were less personalised, but all had the minimum standard of furniture required. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 27 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 & 30 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Whilst an attempt has been made to make better use of resources, the outcome for some resident remains poor. EVIDENCE: The Registered Provider has repeatedly failed to provide ample staff to meet the needs of residents in this particular home. We have made requirements in the past for this to be addressed and it has been an ongoing concern voiced by visiting relatives and healthcare professionals. A lack of compliance in this area resulted in a Statutory Requirement Notice being issued by us in July of this year. Between the issuing of this notice and the current inspection, visiting professionals still had concerns about the numbers of staff in relation to the care needs of the residents. We have subsequently learnt through a regulation 26 report and by talking to visiting healthcare professionals, that the residents on the top floor have been moved, with their consent, making it easier for staff to monitor and work across three floors as opposed to four. On the 10/11/08 the senior manager explained that the home was now being staffed with five care staff from 7am to 7pm (not including registered nurses). We were also informed that their working routines had been reviewed and as part of this review the activities co-ordinator’s hours had altered. She no longer starts at 7am but starts work at 10am and goes straight in to providing Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 28 activities. This avoids the dilemma she was finding herself in at 10am if there were still people to wash, dress and help to feed. The senior company manager agreed that she had increased the staffing to five care staff with the activities co-ordinator being in addition to this from 10am until 4pm because she felt the home required it. There is at least one Registered Nurse on duty each day plus at least one person in a management capacity Monday to Friday. In the last week an acting manager for the home has been identified by the Registered Provider, so on some days there has been two people in a management role, such as throughout this inspection. It was confirmed that these alterations to the staffing numbers and routines have worked well. We asked a carer how many residents he had been responsible for getting up on the 10/11/08 and this had been five. He confirmed that the last person he attended to was at 11.15am and that all had had breakfast. When we arrived at the home on 12/11/08 the senior company manager was not present, but the Director of Care was present throughout the inspection. The newly identified acting manager was also present as she had been on the 10/11/08. The Registered Nurse on duty was from an agency, but she had been to the home previously and presented herself in a very competent manner. At 11.10am we spoke to her and asked why the medication round was taking so long. She explained that trying to give medication out across four floors was difficult and that staff constantly requiring supervision and guidance had also taken up her time. She agreed this had been a distraction when administering medication and one that we would say is unsafe. She had found this to be a great distraction from the task in hand and one that we have flagged up before as leading to potential mistakes being made. This nurse felt that there were a high number of very frail and dependant residents who just could not be rushed. It was this nurse that initially identified the lack of care being given to the resident with the deep pressure sore, from which she was clearly upset and said that she thought the home was inadequately staffed for what had to be done. It was after this incident that we looked at the staffing rosters to ascertain who was on duty. The duty roster conflicted with the record of who had actually arrived for duty in the morning. Both the acting manager and the Director of Care were equally unclear as to who was actually on duty. The Director of Care arrived after our arrival and we understand the acting manager had been on duty from approximately 7.45am. After some investigation in to the incident and as to who was on duty, it was confirmed that in fact there were four care staff on duty with the activities coordinator being in addition to this. The Director of Care initially thought this to be correct until we pointed out that we had been informed on the 10/11/08 that the home was now being staffed with five care staff, plus the activities coordinator. The Director of Care said she had not been very involved in the management of the home up until this point and she needed to clarify this. We were further concerned to learn that two of these care staff were agency staff, Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 29 who did not know the home very well. The third carer had been transferred from a sister home less than a week before and there had already been concerns regarding this person’s current capabilities. This left one permanent carer, the agency nurse and the new acting manager from about 7.45am. Further investigation revealed that one carer had gone off sick and the company’s head office had been unable to replace the morning part of the sick carers shift. As this carer would have normally also have worked until 7pm, by 11.50am the afternoon part of her shift was also still uncovered, with one of the agency carers due to go off duty at 1pm. The numbers of carers would then have dropped to three. At this point we felt that residents’ safety would be further compromised, as well as feeling unsure that the increase in staffing numbers had been firmly agreed. We therefore issued an immediate requirement to ensure that arrangements were made to staff the home appropriately, both in number and skill on the 12/11/08 but also in the future and that the number and skill base required to do this is determined and organised by someone who knows the what the ‘actual’ day to day care needs of the residents. The company informed us that the person best placed to do this would be the newly identified acting manager. We also required the duty rosters, of planned and actual shifts worked, to be fax to the Commission on a weekly basis until further notice. The immediate situation on 12/11/08 was rectified by the Director of Care who asked the agency carer due to go off duty at 1pm, to stay until 3pm, by asking the activities co-ordinator to stop activities at 3pm instead of 4pm and resume care duties and by transferring a carer from a sister home for the rest of the afternoon/evening shift. This carer arrived but had not been in the home before. We were concerned that the residents in the home that this carer had come from would be affected by having one less member of staff. The Director of Care said that although they would be one down, the other staff knew the residents and routine of that home well. Currently, three staff hold the National Vocational Qualification (NVQ) and the company counts the training that another member of staff holds as an equivalent. This is below the national minimum standard of 50 of care staff within a service needing to hold the NVQ or equivalent. We looked at the recruitment records of two staff that have been employed since our last inspection. The first person is from overseas and was initially employed at a sister home for a month prior to transferring to Astley Care Centre. We could see evidence of an interview and that gaps in employment had been explored. Two satisfactory references were obtained before employment. This person was employed before clearance had been obtained from the Criminal Records Bureau (CRB), but clearance against the Protection of Vulnerable Adults (POVA) list and an overseas police check had been obtained before Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 30 employment. A training certificate was seen for safe moving and handling (theory), fire safety, basic food hygiene, infection control, COSHH (control of substances hazardous to health), basic health and safety and its legal framework and RIDDOR (reporting of injuries, diseases and dangerous occurrences). This training was carried out in one day. Further certificates were seen for safe moving and handling (practical) and awareness of abuse and challenging behaviour. The second person’s recruitment file indicated that employment had commenced, but were no recorded checks against CRB or POVA. There was also other information of concern that we would expect the Registered Provider to follow up and risk assess but this was not recorded. Concerned, we subsequently contacted the service for clarification of this person’s employment status. Information was given quickly and we were informed that this person did not start work in the home. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 31 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 & 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Residents are benefiting from what has been a short period of strong leadership; however, any action taken so far has been in response to pressure from outside the service. For residents’ best interests to be properly protected, the service needs to be able to show that it is capable of being independently proactive in wanting to improve outcomes for those living in the home and sustaining them. EVIDENCE: The home has not had consistent management so far this year and this was the case for a good part of 2007 when the last Registered Manager was not able to be in the home as consistently as everyone would have wished. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 32 In 2008 the home has experienced a succession of acting managers, compounded with the uncertainties of a potential sale of the care home, which we understand has fallen through. The Commission is not currently processing any new applications for registration of a new provider or potential registered manager. The Registered Provider has however confirmed that they are advertising for a potential Registered Manager. The Registered Provider has explained that the recent period of instability, compounded with the failings of the last acting manager, has hampered their ability to comply with outstanding enforcement notices. The Commissions view is that the service has continued to provide poor outcomes for residents for sometime now and that repeated requirements span over a period of eighteen months. The senior company manager who has been responsible for managing the home over the last few weeks and achieving some of the recently implemented changes, has a wealth of experience in social care and holds the National Vocational Qualification at Level 4. This person is also the Registered Manager for the company’s Domiciliary Care Agency, amongst other roles and is now working two days a week within the home in an administrative role. The person who has been delegated the task of acting manager until a potential new Registered Manager can be recruited is, already a Registered Manager for one of the company’s sister homes. This person is also a Registered Nurse, so is better placed to know the needs of the residents that require nursing care. She is also one of the company’s moving and handling trainers. Although her she is allocated to work at Astley House for the current time, already there have been times when she has been required to be elsewhere, be it in another home, the head office or at training. In view of the fact that the above arrangement is temporary and because of the shortfalls identified again in this inspection, the safeguarding adults process will continue and external healthcare professionals will continue to monitor and support the service. We do acknowledge the steps that have already been taken by the senior company manager and the acting manager in response to requirements made by us, concerns expressed by relatives and the advice given by visiting professionals. We were quite aware during this inspection that staff are in no doubt about what the current managers’ expectations are. The Registered Provider is also clear about what has to be done to comply with the Care Home Regulations 2001. We have seen records that demonstrate that staff supervision is taking place. Further training has either taken place or is planned, such as the syringe driver training for the two, day nurses on the last day of this inspection. One carer said she had planned to leave but has changed her mind as she feels the home is currently being managed. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 33 We did not inspect residents’ personal monies during this inspection but understand that if a resident wants a small amount of money kept safe, that this can be done and that they have access to this as they wish. In previous inspections we have seen ongoing maintenance records for checking hot water temperatures, emergency lighting and several other areas of general maintenance and health and safety. These were not seen during this inspection but we have no reason to believe that this system has altered in any way and will request these at some point in the future. Hoists used for safe moving of residents are serviced regularly. We have seen safety certificates for gas safety and boiler servicing. We are in communication with the Health and Safety Executive (HSE) who visited the home in December 2007. This resulted in an enforcement letter being issued by the HSE Inspector. The HSE continue to inspect the ‘Blanchworth Group’ corporate policies and policies relating to health and safety, which are used within Astley House. The Commission is aware of the company’s audit and quality assurance systems, but despite these some action is only taken when a shortfall is pointed out to the service or when some form of enforcement action is issued. In the latter case the service has still not complied. We are receiving regulation 26 reports on a regular basis from the acting manager and we will continue to use these as one way of monitoring the home. In this report we have acknowledged some positive changes that have resulted from recent leadership provided by one of the company’s senior managers and what action the new acting manager took during this inspection, when shortfalls were pointed out. Additional action and changes in the home have been to ongoing requirements made by us and others are in response to recent concerns and a complaint received from relatives. Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 34 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 1 1 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 3 X X 3 X 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 1 X X 2 X 2 Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 35 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 31/12/08 1 OP7 14(2) The Registered Person must make sure that any additional assessment, such as those relating to moving and handling, nutrition and wound care are completed competently, when required and the information cross referenced with the care plan. (Timescale of the 25/07/08 & 15/08/08 not met). The Registered Person must ensure that the care plans give clear guidance to staff on how individual care needs are to be met and that they are updated and kept relevant to the residents needs. (Timescale of the 25/07/08 & 15/08/08 not met) The Registered Person must ensure that all staff delivering care within the home are aware of the guidance given within individuals’ care plans and that they adhere to this in order that DS0000016373.V372942.R01.S.doc 2 OP7 15(1)(2) 31/12/08 3 OP8 12(1)(a) (b) 31/12/08 Astley House Care Centre Version 5.2 Page 36 the correct and agreed care is given to the resident. (Previous timescale of 31/01/08, 25/07/08 & 15/08/08 not fully met) 4 OP8 12(1)(b) The Registered Person must 13/12/08 make safe and effective arrangements for ensuring that service users receive proper provision for care, treatment and supervision in respect of pressure area care and any other wound care. (Previous timescale of 31/01/08 25/07/08 & 15/08/08 not met including the Statutory Requirement Notice of the 02/07/08) When staff administer any medicines to people living in the home they must always follow safe procedures and immediately make a complete and accurate record of this action. (This particularly relates to the poor practice of signing medicine records retrospectively and the inconsistent recording of the application of any prescribed medication that is applied topically). This will help to make sure people receive the correct levels of medication and are not put at unnecessary risk. When any medicines are prescribed to be administered ‘when required’ make sure that there is clear and specific written guidance to staff on how to reach decisions so as to consistently administer each particular medicine in accordance with that person’s needs. This will help to make sure people receive the correct DS0000016373.V372942.R01.S.doc 5 OP9 13(2) 31/12/08 6 OP9 13(2) 31/12/08 Astley House Care Centre Version 5.2 Page 37 7 OP9 18 levels of medication in accordance with their needs and planned actions. When medicines are 31/12/08 administered to people in the home via a syringe driver you must make sure that all registered nurses who are responsible for the management of this treatment have up to date training, by a professionally recognised trainer, in the setting up and use of syringe drivers. This is to make sure the health, safety & welfare of people living in the home is maintained. (Timescale of the 30/09/08 has been extended) The Registered Person must ensure that residents are helped to eat and drink at times that suit them, at intervals that avoid long periods of being without food or fluid and with the knowledge that some residents require extra support in this area because of specific health needs. (Timescale of 01/08/07, 31/01/08 & 25/07/08 not fully met) The Registered Person must ensure that the services provided in the home match with those written within the home’s Statement of Purpose in order to protect vulnerable people living in the home. (Timescale of the 25/07/08 not fully met). 13/12/08 8 OP12 12(3) 9 OP18 16(1) 13/12/08 10 OP27 18(1)(a) The Registered Person must 13/12/08 ensure there are sufficient, suitably qualified, competent and experienced staff working at the home at all times to meet the assessed needs and carry out DS0000016373.V372942.R01.S.doc Version 5.2 Page 38 Astley House Care Centre the plan of care of each resident. (This requirement has been repeated from previous inspections. Recent timescales of the 21/01/08 & 25/07/08 also not met. Statutory Requirement Notice of the 04/07/08 not complied with). 11 OP31 10 The Registered Provider must 13/12/08 make sure that the ‘new’ management arrangements identified in this report remain consistent, on a day-to-day basis so as to ensure the health, welfare and safety of service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Astley House Care Centre DS0000016373.V372942.R01.S.doc Version 5.2 Page 39 Commission for Social Care Inspection South West Colston 33 33 Colston Avenue Bristol BS1 4UA National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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